Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: https://www.bmj.com/company/legal-information/
Re: Corticosteroid therapy for sepsis: a clinical practice guideline
In this clinical practice guideline, we were deeply impressed by the stringent recommendation towards the corticosteroid treatment for sepsis.1 Among a rapid recommendation triggered by two trials, hydrocortisone plus fludrocortisone improved the 90-day mortality especially among these patients with seriously septic shock In the landmark study 2 compared with that of the ADRENAL trial.3 The therapeutic effects low-dose hydrocortisone on its symptom and prognosis remained appealing whether adding fludrocortisones. No between-group differences with regard to 28-day mortality indicated that some patients with septic shock possessed completely dysregulated host responsiveness to infections termed as “past hope” although these secondary outcomes were temporarily improved, indicating the importance of endogenous determinants of differential circulation, cell metabolism and gene polymorphism in sepsis.4 The 90-day beneficial effects further demonstrated the internal regulatory network (neuroendocrine-immune, inflammation, etc.) may propel the body’s recovery with the aid of corticosteroids in a safe and efficacious manner beyond hyperglycemia. Concerning the mild-moderate septic shock, the usage of hydrocortisone and controversial fludrocortisones 2,5 should be wisely chosen regarding individualized septic symptoms by clinicians. Additionally, the limited therapeutic value of insulin 6 and highlighted 90-day survival suggested that the glycemic control (≤150 mg/dl) isn’t likely a key intervention compared with mechanical ventilation6 in septic shock. Analysis of quality of life in the ADRENAL trial is also preferred for the overall effect estimates. Thus, additional adaptive RCTs help to resolve remaining uncertainty rather than a small mortality reduction in sepsis.
Ce Yang M.D., Liyong Chen M.D., Jianxin Jiang M.D. State Key Laboratory of Trauma, Burns and Combined Injury, Research Institute of Surgery, Daping Hospital, the Third Military Medical University, Chongqing 400042, China
Corresponding Author: C Yang, MD, State Key Laboratory of Trauma, Burns and Combined Injury, Research Institute of Surgery, Daping Hospital, the Third Military Medical University, Chongqing 400042, China (sepsismd@126.com).
Author Affiliations: State Key Laboratory of Trauma, Burns and Combined Injury, Research Institute of Surgery, Daping Hospital, the Third Military Medical University, Chongqing 400042, China (Yang, Jiang); Department of Anesthesiology, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China (Chen).
REFERENCES
1. Lamontagne F, Rochwerg B, Lytvyn L, et al. Corticosteroid therapy for sepsis: a clinical practice guideline. BMJ 2018;362:k3284 doi: 10.1136/bmj.k3284 pmid: 30097460.
2. Annane D, Renault A, Brun-Buisson C, et al. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. N Engl J Med 2018;378(9):809-18 doi: 10.1056/NEJMoa1705716 pmid: 29490185.
3. Venkatesh B, Finfer S, Cohen J, et al. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. N Engl J Med 2018;378(9):797-808 doi: 10.1056/NEJMoa1705835 pmid: 29347874.
4. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017;43(3):304-77 doi: 10.1007/s00134-017-4683-6 pmid: 28098591.
5. Investigators CS, Annane D, Cariou A, et al. Corticosteroid treatment and intensive insulin therapy for septic shock in adults: a randomized controlled trial. JAMA 2010;303(4):341-8 doi: 10.1001/jama.2010.2 pmid: 20103758.
6. Fan E, Brodie D, Slutsky AS. Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment. JAMA 2018;319(7):698-710 doi: 10.1001/jama.2017.21907 pmid: 29466596.
Competing interests:
No competing interests
14 August 2018
Ce Yang
Doctor
Liyong Chen, Jianxin Jiang
State Key Laboratory of Trauma, Burns and Combined Injury, Research Institute of Surgery, Daping Hospital, the Third Military Medical University
Rapid Response:
Re: Corticosteroid therapy for sepsis: a clinical practice guideline
In this clinical practice guideline, we were deeply impressed by the stringent recommendation towards the corticosteroid treatment for sepsis.1 Among a rapid recommendation triggered by two trials, hydrocortisone plus fludrocortisone improved the 90-day mortality especially among these patients with seriously septic shock In the landmark study 2 compared with that of the ADRENAL trial.3 The therapeutic effects low-dose hydrocortisone on its symptom and prognosis remained appealing whether adding fludrocortisones. No between-group differences with regard to 28-day mortality indicated that some patients with septic shock possessed completely dysregulated host responsiveness to infections termed as “past hope” although these secondary outcomes were temporarily improved, indicating the importance of endogenous determinants of differential circulation, cell metabolism and gene polymorphism in sepsis.4 The 90-day beneficial effects further demonstrated the internal regulatory network (neuroendocrine-immune, inflammation, etc.) may propel the body’s recovery with the aid of corticosteroids in a safe and efficacious manner beyond hyperglycemia. Concerning the mild-moderate septic shock, the usage of hydrocortisone and controversial fludrocortisones 2,5 should be wisely chosen regarding individualized septic symptoms by clinicians. Additionally, the limited therapeutic value of insulin 6 and highlighted 90-day survival suggested that the glycemic control (≤150 mg/dl) isn’t likely a key intervention compared with mechanical ventilation6 in septic shock. Analysis of quality of life in the ADRENAL trial is also preferred for the overall effect estimates. Thus, additional adaptive RCTs help to resolve remaining uncertainty rather than a small mortality reduction in sepsis.
Ce Yang M.D., Liyong Chen M.D., Jianxin Jiang M.D. State Key Laboratory of Trauma, Burns and Combined Injury, Research Institute of Surgery, Daping Hospital, the Third Military Medical University, Chongqing 400042, China
Corresponding Author: C Yang, MD, State Key Laboratory of Trauma, Burns and Combined Injury, Research Institute of Surgery, Daping Hospital, the Third Military Medical University, Chongqing 400042, China (sepsismd@126.com).
Author Affiliations: State Key Laboratory of Trauma, Burns and Combined Injury, Research Institute of Surgery, Daping Hospital, the Third Military Medical University, Chongqing 400042, China (Yang, Jiang); Department of Anesthesiology, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China (Chen).
REFERENCES
1. Lamontagne F, Rochwerg B, Lytvyn L, et al. Corticosteroid therapy for sepsis: a clinical practice guideline. BMJ 2018;362:k3284 doi: 10.1136/bmj.k3284 pmid: 30097460.
2. Annane D, Renault A, Brun-Buisson C, et al. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. N Engl J Med 2018;378(9):809-18 doi: 10.1056/NEJMoa1705716 pmid: 29490185.
3. Venkatesh B, Finfer S, Cohen J, et al. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock. N Engl J Med 2018;378(9):797-808 doi: 10.1056/NEJMoa1705835 pmid: 29347874.
4. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017;43(3):304-77 doi: 10.1007/s00134-017-4683-6 pmid: 28098591.
5. Investigators CS, Annane D, Cariou A, et al. Corticosteroid treatment and intensive insulin therapy for septic shock in adults: a randomized controlled trial. JAMA 2010;303(4):341-8 doi: 10.1001/jama.2010.2 pmid: 20103758.
6. Fan E, Brodie D, Slutsky AS. Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment. JAMA 2018;319(7):698-710 doi: 10.1001/jama.2017.21907 pmid: 29466596.
Competing interests: No competing interests